Autopsy (cont.)

Melissa Conrad Stöppler, MD

Melissa Conrad Stöppler, MD, is a U.S. board-certified Anatomic Pathologist with subspecialty training in the fields of Experimental and Molecular Pathology. Dr. Stöppler's educational background includes a BA with Highest Distinction from the University of Virginia and an MD from the University of North Carolina. She completed residency training in Anatomic Pathology at Georgetown University followed by subspecialty fellowship training in molecular diagnostics and experimental pathology.

Jay W. Marks, MD

Jay W. Marks, MD, is a board-certified internist and gastroenterologist. He graduated from Yale University School of Medicine and trained in internal medicine and gastroenterology at UCLA/Cedars-Sinai Medical Center in Los Angeles.

What other special studies may be done as part of the autopsy?

Pictures of findings may be taken for future reference. Special studies may include cultures to identify infectious agents, chemical analysis for the measurement of drug levels or metabolic abnormalities, or genetic studies. Tissue may be frozen for future diagnostic or research purposes. Organs may be preserved and stored in formalin for later examination, sampling for microscopy, presentation at conferences, or archiving for the training of medical students.

What is the autopsy report?

After all studies are completed, a detailed report is prepared that describes the autopsy procedure and microscopic findings, gives a list of medical diagnoses, and a summary of the case. The report emphasizes the relationship or correlation between clinical findings (the doctor's examination, laboratory tests, radiology findings, etc.) and pathologic findings (those made from the autopsy).

Why is the autopsy rate declining?

Beginning in the 1950s, hospital autopsy rates started falling from an average of around 50% of all deaths to 10% in the late 1990s. Currently, the rates are even lower at non-academic hospitals. In 1970, the Joint Commission for Accreditation of Hospitals dropped the requirement that a hospital needed an autopsy rate of 20% to be accredited.

Family factors: Certainly the relationship between patients and their doctors has changed dramatically over the past 50 years due to factors such as specialization, managed care, and the disappearance of the "house call." Physicians no longer are "family doctors" and do not have the same rapport with patients and their families as in past years. This change in the basic doctor-patient relationship may make it increasingly difficult to obtain consent for an autopsy.

Concerns over disfigurement of the remains or delays in funeral arrangements may prevent a vast majority of families from consenting to an autopsy. In reality, however, the visual examination of the body and the removal of tissues and organs for microscopic examination can be completed in a few hours. Furthermore, there are no visible external changes that would preclude an open-casket funeral service.

In the majority of cases and certainly at academic medical centers, there is currently no charge to the family. More recently, though, some institutions have started to charge and private autopsies at the request of family members that are performed outside of the hospital may cost several thousand dollars.

Clinician factors: Most physicians are generally uncomfortable requesting an autopsy because it is not an easy or pleasant task. If, in addition, a physician feels that a family questions the care that their relative was given, the physician may be reluctant to request an autopsy that might prove that the care was indeed incorrect.

Many individuals in medicine feel that modern technology has made the autopsy outdated or obsolete. With modern imaging studies and laboratory tests, it is thought that the autopsy is unlikely to reveal any conditions that were not detected clinically. The accuracy of the clinical diagnosis has been the subject of numerous research studies. These studies have consistently shown that in 20% to 40% of autopsied patients, there were important, treatable conditions that were detected at autopsy that were not diagnosed clinically. This consistent and significant discrepancy between clinical and pathologic diagnoses is probably the most compelling argument for continued efforts to revive the autopsy as the "gold standard" in evaluating the quality of medical care.

Pathologist factors: Some doctors express dissatisfaction with the quality of an autopsy if the pathologist does not provide answers regarding the case. Unfortunately, an autopsy does not guarantee that the cause of death, for example a heart arrhythmia, will be identified.

Autopsy pathology is a vanishing subspecialty, which, for the most part, has been relegated to a secondary position. At the turn of the century, most of the pathologist's activities revolved around the autopsy. Since that time, laboratory medicine and surgical pathology (examining tissue biopsies from living patients) have become the major activities of practicing pathologists.

In addition, the autopsy is not one of the favorite activities among the majority of pathologists. For many pathologists, an autopsy is an extra burden with no compensation during a busy day.